Numerous theories have tried to explain the spread of organisms from oropharynx to the surrounding vein haematogenous via the tonsillar vein, secondary to lymphangitis or via direct spread through deep neck spaces. To note there are reported cases of LS in which there was no demonstrable vascular involvement. This unusual finding helps to highlight the variable nature of this condition and the diagnostic confusion it may herald. Studies have previously described LS with thrombosis of the carotid artery, intracranial venous sinus and abdominopelvic vessels ( 1) only three have ever described involvement of the EJV. Lastly an echocardiogram was sought confirming a normal heart with no septal defects, vegetations or thrombus.ĭespite IJV thrombophlebitis forming a main diagnostic criterion for LS, we report a case in which the primary vascular involvement is that of the EJV, with a corresponding normal IJV. Despite a coincidental finding of a smaller calibre left venous sinus thrombus was not seen to extend intracranially. To note the left IJV remained patent with good demonstrable flow.Īn MRI brain with venography (MRV) sequences provided greater anatomical delineation ( figure 1). These veins appeared dilated with increased wall vascularity and showed no recordable signal on doppler imaging, an appearance in keeping with an inflammatory thrombophlebitis. Initial imaging of the neck comprised an ultrasound scan this demonstrated normal right sided vasculature but abnormal left EJV and retromandibular veins. A chest x-ray showed clear lung fields with no pulmonary lesions. A septic screen was undertaken and blood cultures obtained. Initial blood results showed an elevated C-reactive protein of 155mg/L and white cell count of 16.6(10*9L). Further systems examinations were unremarkable, observations were stable and he remained afebrile.

Lymphadenopathy was present and limited to the left submandibular area.Įxamination of the oral cavity was complicated by trismus, however no obvious tonsillar enlargement, erythema or exudate was recorded. A provisional diagnosis of tonsillitis had been made five days earlier by the local GP and a course of erythromycin and penicillinV commenced.Įxamination revealed tender swellings over the left temporal area, angle of the mandible and upper third of the sternocleidomastoid extending into the submandibular region. Minor systemic upset was also noted including headache, vomiting and non specific abdominal pain. A twelve year old boy presented to the children’s assessment unit with a 24 hour history of unilateral face and neck swelling on a background of seven days progressive sore throat and dysphagia.

Calibre press u neck and throat